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eLetters

831 e-Letters

Dear Editor,
I read with interest this article by Keep et al. There is clearly growing interest in research aiming to identify patients with sepsis earlier in emergency departments, given evidence that early treatment seems to improve outcomes.
However, I am not sure of the usefulness of comparing one scoring system (NEWS) to another (Surviving Sepsis Campaign definitions). As both are composites of mostly physiological variable...

Dear Editor,
I read with interest this article by Keep et al. There is clearly growing interest in research aiming to identify patients with sepsis earlier in emergency departments, given evidence that early treatment seems to improve outcomes.
However, I am not sure of the usefulness of comparing one scoring system (NEWS) to another (Surviving Sepsis Campaign definitions). As both are composites of mostly physiological variables, it is not particularly surprising that they are closely related.
The major problem is that both scoring systems do not have a particularly strong relationship to mortality. Previous research on EWS in sepsis have shown AUC figures of around 0.6-0.7, much less than the figures presented here (1-3). A recent paper by Kaukonen et al (4) (published after this paper was submitted), has shown that the SIRS criteria are also not particularly ideal for defining 'cut off points' in patients with sepsis.
The authors suggest that using an EWS of >=3 has a NPV of 99.5% for 'severe sepsis', and a specificity of 77%. However, in Corfield et al's paper on sepsis mortality, the same cut off has an NPV of only 92.3% and a specificity of 11%(1)!
Subsequent data from that paper show that the mortality of patients with NEWS between 0-4 are almost identical (EWS =0, mortality 18.8%, EWS = 1, mortality 18.8%, EWS =2, mortality 19.3%, EWS=3, mortality = 20%, EWS =4, mortality = 21.3%).
Without presenting figures for mortality in this dataset, it is hard to know the relevance of using the cut off they suggest. Sepsis is clearly a condition which has a significant mortality attached, but this does not appear to be well related to either SSC definitions or EWS figures, apart from in extremes.
Did the authors collect any mortality or outcome data in this cohort?
Thanks,
Fergus Hamilton
1 )Corfield, A. R., Lees, F., Zealley, I., Houston, G., Dickie, S., Ward, K., & McGuffie, C. (2014). Utility of a single early warning score in patients with sepsis in the emergency department. Emergency Medicine Journal : EMJ, 31(6), 482-7. doi:10.1136/emermed-2012-202186
2) ??ld?r, E., Bulut, M., Akal?n, H., Kocaba?, E., Ocako?lu, G., & Ayd?n, ?. A. (2013). Evaluation of the modified MEDS, MEWS score and Charlson comorbidity index in patients with community acquired sepsis in the emergency department. Internal and Emergency Medicine, 8(3), 255-60. doi:10.1007/s11739-012-0890-x
3) Geier, F., Popp, S., Greve, Y., Achterberg, A., Gl?ckner, E., Ziegler, R., ... Christ, M. (2013). Severity illness scoring systems for early identification and prediction of in-hospital mortality in patients with suspected sepsis presenting to the emergency department. Wiener Klinische Wochenschrift, 125(17-18), 508-15. doi:10.1007/s00508-013-0407-2
4)Kaukonen, K.-M., Bailey, M., Pilcher, D., Cooper, D. J., & Bellomo, R. (2015). Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. New England Journal of Medicine, 372(17), 150317020036009. doi:10.1056/NEJMoa1415236

Conflict of Interest:

Dear editor
I wish to congratulate the authors of the HIRT trial on finally publishing
their results. Whilst a negative trial for primary outcomes, to me it
highlighted the major challenges in conducting high quality RCTs in
prehospital setting. Few countries have been able to perform this level of
prehospital research and it can only advance the future planning of
prehospital studies trying to examine the very same questi...

Dear editor
I wish to congratulate the authors of the HIRT trial on finally publishing
their results. Whilst a negative trial for primary outcomes, to me it
highlighted the major challenges in conducting high quality RCTs in
prehospital setting. Few countries have been able to perform this level of
prehospital research and it can only advance the future planning of
prehospital studies trying to examine the very same questions.In one
regard, I view this as a positive result in that it showed advanced ground
paramedic care in the Sydney region of New South Wales,provided quality
care to severe head injured patients that was not significantly improved
upon by addition of a prehospital HEMS physician led team.

The other prehospital RCT of advanced interventions including RSI
for severe head injured patients was another Australian study by Bernard
et al in Melbourne, Victoria and this did show improved eGOS. It was a
paramedic delivered RSI intervention and therefore taken together HIRT and
the Melbourne MICA trial would suggest adding prehospital RSI to the NSW
paramedic skill set might in fact be the more EBM supported approach for
the severe head injured patient.

Conflict of Interest:

We congratulate the authors on this excellent piece of work and are
particularly pleased to see method of arrival in their tool as a predictor
of admission. In a similar piece of work to predict surgical admissions
in our institution we found the same effect (1). At a time when it seems
to be politically expedient to scapegoat patients for the overcrowding in
our departments and lack of available beds on the wards it is...

We congratulate the authors on this excellent piece of work and are
particularly pleased to see method of arrival in their tool as a predictor
of admission. In a similar piece of work to predict surgical admissions
in our institution we found the same effect (1). At a time when it seems
to be politically expedient to scapegoat patients for the overcrowding in
our departments and lack of available beds on the wards it is helpful to
show that those who call 999 are found to be genuinely sicker!

(1) Who needs an expert? A tool for optimal triage of general
surgical patients in the Emergency Department. European Journal of Trauma
and Emergency Surgery
April 2014, Volume 40, Issue 1 Supplement, S76

Conflict of Interest:

We would like to thank the authors of this study both for reminding
us of what is our primary objective as healthcare providers -- to relieve
pain and suffering; and for providing the evidence that suggests that we
often are failing in this objective. As medical crewmembers in helicopter
EMS, we appreciate the need to elicit accurately, and to relay
effective...

We would like to thank the authors of this study both for reminding
us of what is our primary objective as healthcare providers -- to relieve
pain and suffering; and for providing the evidence that suggests that we
often are failing in this objective. As medical crewmembers in helicopter
EMS, we appreciate the need to elicit accurately, and to relay
effectively, information about a patient's pain and suffering. We believe
that the PENS tool is effective in meeting these objectives.

The authors remind us that managing a patient's pain and suffering
requires that healthcare providers be aware of the constellation of
unpleasant sensations experienced by the patient. These sensations may be
caused by illness or injury (i.e., their pain). Their pain, a distinct
entity, may be associated with both mental and emotional distress, such as
fear, anxiety, and uncertainty; and with physical sensations caused by
hunger, thirst, nausea, dizziness, fatigue, and the unpleasant features of
ambient light, temperature, and noise (i.e., their suffering).

Managing pain and suffering begins with asking the right questions.
PENS, an acronym pronounced as a word, is an abbreviation for the elements
of Pain/Discomfort; Emotions/Expectations; Nausea/Nutrition (Elimination);
and Sensory-Stimuli/Sleep. The "PENS assessment" begins with asking the
patient: "Are you in pain?" It ends with asking: "Is there anything else
that I can do for you?"

We use PENS in transport medicine as a prompt to ask questions that
allow us to mitigate pain and suffering in both initial and subsequent
patient assessments. We use the "E" for "Expectations" in PENS as a prompt
for asking the patient questions such as: "Do you understand what our
plans are?" because such questions provide the means for initial creation
and ongoing modification of healthcare plans, and are the basis for shared
decision-making. We have found that during transitions of care
("handoffs") the information that we elicited from PENS assessments is the
type of information that other healthcare providers often find most
useful. Finally, we have found the PENS tool to be easy to remember, and
simple to apply.

Conflict of Interest:

I read with interest the study by Bloch and Bloch demonstrating the
effectiveness of observation-based simulation training. As they discussed,
simulation training not only improves attendees' knowledge and skills but
can also improve teamwork and communication[1].

As reflected in this article, simulation training is typically run on
a departmental basis. However, increasingly emergency medicine involves a
multidi...

I read with interest the study by Bloch and Bloch demonstrating the
effectiveness of observation-based simulation training. As they discussed,
simulation training not only improves attendees' knowledge and skills but
can also improve teamwork and communication[1].

As reflected in this article, simulation training is typically run on
a departmental basis. However, increasingly emergency medicine involves a
multidisciplinary team. In the particular case of paediatric
resuscitation, in many hospitals the paediatric cardiac arrest team may
comprise emergency physicians, paediatricians and anaesthetists, as well
of course as emergency and paediatric nursing staff, all of whom may train
separately in their own departments. This can lead to incongruities in the
approach that is taught, and is a missed opportunity to foster better
teamwork and communication between the doctors and allied health
professionals playing these different roles during the management of time-
critical emergencies.

Just as there is a drive for conformity in the design and
availability of equipment for emergencies, which has been identified as an
important factor in increasing the efficacy and efficiency of care for
critically ill patients[2], perhaps the need for better conformity of
training also needs to be recognised. As this paper demonstrates the
effectiveness of observation-based simulation training, this may open a
way for multiple departments to train jointly, so that the
multidisciplinary team managing paediatric emergencies develop a cohesive
approach with stronger interdisciplinary communication and and teamwork.

Conflict of Interest:

I agree with Antrum and Ho (EMJ 2015;32:171-172) that formal Pre-
Hospital Training should be included in all Undergraduate Medical
Curriculums. They will be pleased to hear that a nationwide Faculty of Pre
-Hospital Care Undergraduate Committee has been set-up, aiming to
springboard ideas and information about events, funding and training in
pre-hospital care, to all healthcare students.
Antrum and Ho quite rightly realis...

I agree with Antrum and Ho (EMJ 2015;32:171-172) that formal Pre-
Hospital Training should be included in all Undergraduate Medical
Curriculums. They will be pleased to hear that a nationwide Faculty of Pre
-Hospital Care Undergraduate Committee has been set-up, aiming to
springboard ideas and information about events, funding and training in
pre-hospital care, to all healthcare students.
Antrum and Ho quite rightly realise that some form of compulsory pre-
hospital training in all medical curriculums is only likely to happen if
the General Medical Council specifically requests it.
However at present, evidence to illustrate to the GMC the real value of
such training is lacking. This must change if it is to be a credible
competitor for precious curriculum time.
The Undergraduate Pre-Hospital Care Committee hopes that through co-
ordination of student pre-hospital care events, sharing of information and
literary review, as well as a now standardised and followed-up feedback
system for pre-hospital training, the evidence-base will grow. I urge
anyone involved in student pre-hospital care activities throughout the UK,
to get in touch with the Committee and together let's make sure the
necessary evidence for such vital training actually exists.

Conflict of Interest:

Antrum and Ho (EMJ 2015;32:171-172) identify an important issue in identifying the deficiency in medical education due to the lack of formal training in pre-hospital medical care at most medical schools in the UK.

There are obvious benefits of increasing the number of trained professionals able to provide pre-hospital care it is important that all medical gradua...

Antrum and Ho (EMJ 2015;32:171-172) identify an important issue in identifying the deficiency in medical education due to the lack of formal training in pre-hospital medical care at most medical schools in the UK.

There are obvious benefits of increasing the number of trained professionals able to provide pre-hospital care it is important that all medical graduates have knowledge of twenty first century management of emergencies in the pre-hospital situation. However in this area of medicine, where any medical practitioner can unexpectedly be required to help, it is important to ensure all medical graduates have knowledge of what interventions should not be undertaken as well as these that should be undertaken.

With a new GMC recognised sub-speciality of Pre-Hospital Emergency Medicine it is timely that the teaching of undergraduate of pre-hospital emergency medicine is standardised within the undergraduate curriculum.

Conflict of Interest:

Your article on ED patients' suffering came to me only this week
through Medscape.com. I would like to thank you for your analysis and for
bringing this topic to the surface.

I have been waiting thirty years for this concept to be treated in
the scientific literature. When I started practice in 1983 in a busy urban
academic Emergency Department in Baltimore, Maryland, and for the next
twenty-five years, THIS was...

Your article on ED patients' suffering came to me only this week
through Medscape.com. I would like to thank you for your analysis and for
bringing this topic to the surface.

I have been waiting thirty years for this concept to be treated in
the scientific literature. When I started practice in 1983 in a busy urban
academic Emergency Department in Baltimore, Maryland, and for the next
twenty-five years, THIS was the main driver of my practice style. It was
very rewarding and I am thrilled to see it championed so.

Most Sincerely,

Steven L. Joffe, M.D.

Conflict of Interest:

An alternative to the use of a bite guard in conjunction with the LMA
would be to employ the intubating laryngeal mask airway (iLMA), since the
single-use version of the iLMA has a rigid plastic airway tube which
resists occlusion by biting, as does the silicone-coated stainless steel
tube with the reusable version. Additional benefits would be that the iLMA
can facilitate seamless progression to blind tracheal intubation...

An alternative to the use of a bite guard in conjunction with the LMA
would be to employ the intubating laryngeal mask airway (iLMA), since the
single-use version of the iLMA has a rigid plastic airway tube which
resists occlusion by biting, as does the silicone-coated stainless steel
tube with the reusable version. Additional benefits would be that the iLMA
can facilitate seamless progression to blind tracheal intubation without
any interruption in oxygenation or ventilation, and the fact that there is
no separate bite guard to become dislodged and obstruct the patient's
airway.

Conflict of Interest:

Skrobo and Kelleher rightly stress the importance of accurate, rapid
weight estimation in children when the situation precludes actual
measurement of their weight.[1] They also rightly emphasise the need for
estimation tools to be validated locally.

The CORKSCREW study convincingly demonstrates that the mean bias of
weight estimates using the Luscombe formula (3xage+7) is much smaller than
that...

Skrobo and Kelleher rightly stress the importance of accurate, rapid
weight estimation in children when the situation precludes actual
measurement of their weight.[1] They also rightly emphasise the need for
estimation tools to be validated locally.

The CORKSCREW study convincingly demonstrates that the mean bias of
weight estimates using the Luscombe formula (3xage+7) is much smaller than
that for the old APLS formula (2xage+8). Interestingly, this was true for
1-5 year olds too, which suggests that it might be better to use the
Luscombe formula in all children, rather than just in 6-12 year olds as
recommended in the latest APLS manual.

However, the authors have not provided any results for the precision
of these methods, although they suggest that estimates should be within
15% of actual weight. The ISO standard for accuracy of measurement methods
defines both trueness and precision.[2] Trueness is the closeness of
agreement between the arithmetic mean of a large number of test results
and the true or accepted reference value. This is what the CORKSCREW study
has presented. Precision refers to the closeness of agreement between test
results. It is quite easy for a method to have very good trueness (for
example, using the median weight for a given age, as found on standard age
-weight curves), but have such an imprecision that it is clinically
useless. One commonly used method to describe trueness and precision is
described by Bland Altman.[3] The bias reflects trueness, and the limits
of agreement (LOA) reflect precision. For a given weight estimate, LOA
indicate the range of actual weights within which 95% of subjects will
fall.

Of the published methods of paediatric weight estimation, age-based
methods have the worst precision, deteriorating with increasing age.[4] We
would be particularly wary of using age-based weight estimation in
teenagers, as the range of weights for a given age is far too broad to
allow meaningful estimates in individuals. In comparison, the Broselow
tape is a very precise method in children, but not useful in over 10s.[5]
Newer methods of estimation based on mid-arm circumference (MAC) appear to
be at least as precise as the Broselow tape in older children and
adolescents.[6,7]

Of course, tape-based methods require the presence of the child, and
age-based methods might still have a role to play during preparation for a
child's arrival in the resuscitation room. A MAC tape could be readily
available pre-hospital as well as in the emergency department, and useful
when the condition of the patient precludes objective measurement of their
weight.